Improving Outcomes by Implementing a Pressure Ulcer Prevention Program (PUPP): Going beyond the Basics

Evaluation of an Evidence-Based Care Bundle for Preventing Hospital-Acquired Pressure Injuries in High-Risk Surgical Patients

The aim of this study was to evaluate the effectiveness of an evidence-based care bundle to prevent perioperative pressure injuries. In a single facility, using a preintervention and postintervention quasi-experimental design, we compared the pressure injury incidence rate for two patient groups (ie, before and after care bundle implementation). The bundle included a variety of elements, such as educating patients, applying protection, controlling skin moisture, and using pressure-relieving devices according to the patient's risk. Before the intervention, patients received standard care before procedures that did not address risk for pressure injury development. The study involved a total of 944 patients, and the incidence of pressure injury was lower in the postintervention group than in the preintervention group (1.6% versus 4.8%; P < .001). However, the odds ratio was nonsignificant and therefore the clinical relevance of the bundle is unclear. Additional research with a control group and multiple sites is needed.

Pressure injury prevention practice in Australian intensive care units: A national cross-sectional survey

INTRODUCTION

Pressure injury (PI) is an ongoing problem for patients in intensive care units (ICUs). The aim of this study was to explore the nature and extent of PI prevention practices in Australian adult ICUs.

MATERIALS AND METHODS

An Australian multicentre, cross-sectional study was conducted via telephone interview using a structured survey instrument comprising six categories: workplace demographics, patient assessment, PI prevention strategies, medical devices, skin hygiene, and other health service strategies. Publicly funded adult ICUs, accredited with the College of Intensive Care Medicine, were surveyed. Data were analysed using descriptive statistics and chi-square tests for independence to explore associations according to geographical location.

RESULTS

Of the 75 eligible ICUs, 70 responded (93% response rate). PI was considered problematic in two-thirds (68%) of all ICUs. Common PI prevention strategies included risk assessment and visual skin assessment conducted within at least 6 h of admission (70% and 73%, respectively), a structured repositioning regimen (90%), use of barrier products to protect the skin (94%), sacrum or heel prophylactic multilayered silicone foam dressings (88%), regular PI chart audits (96%), and PI quality improvement projects (90%). PI prevention rounding and safety huddles were used in 37% of ICUs, and 31% undertook PI research. Although most ICUs were supported by a facility-wide skin integrity service, it was more common in metropolitan ICUs than in rural and regional ICUs (p < 0.001). Conversely, there was greater involvement of occupational therapists in PI prevention in rural or regional ICUs than in metropolitan ICUs (p = 0.026).

DISCUSSION AND CONCLUSION

This is the first study to provide a comprehensive description of PI prevention practices in Australian ICUs. Findings demonstrate that PI prevention practices, although nuanced in some areas to geographical location, are used in multiple and varied ways across ICUs.

Pressure injury prevention practice and associated factors among nurses at Wolaita Sodo University Teaching and Referral Hospital, South Ethiopia: a cross-sectional study

OBJECTIVE

The prevention of pressure injury is of great importance in providing quality care to patients, as it has been reported that approximately 95% of all pressure injury are preventable. Nurses working in clinical settings play a key role in identifying patients at risk and administering preventative care. Therefore, this study examines pressure injury prevention practices among nurses.

DESIGN

Cross-sectional study design.

SETTING

Wolaita Sodo University Teaching and Referral Hospital, Ethiopia.

PARTICIPANTS

240 nurses.

MAIN OUTCOME MEASURES

Pressure injury prevention practices among nurses.

RESULT

Among nurses, 37.9% had good pressure injury prevention practices. The factors associated with pressure injury prevention practices included having a bachelor's degree or higher (adjusted odds ratio (AOR)=2.18; 95% CI 1.12 to 4.25), having more than 10 years of nursing experience (AOR=3.44; 95% CI 1.41 to 8.37), lacking subject knowledge (AOR=0.49; 95% CI 0.27 to 0.91) and being over the age of 40 (AOR=0.55; 95% CI 0.09 to 0.35).

CONCLUSION

The majority of nurses reported having a limited level of pressure injury prevention practice. Since pressure ulcer prevention practice is majorly the role of nurses. Upgrading the educational level of the nurses through continuous professional development opportunities can improve the preventive practice of pressure ulcer injury by increasing the knowledge and skill gained during the vocational training.

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BACKGROUND

Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.

OBJECTIVES

The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.

METHODS

A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.

RESULTS

Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126).

CONCLUSIONS

We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

The Effectiveness of Care Bundles Including the Braden Scale for Preventing Hospital Acquired Pressure Ulcers in Older Adults Hospitalized in ICUs: A Systematic Review

Background:

Despite technological and scientific advances, Hospital Acquired Pressure Ulcers (HAPUs) remain a common, expensive, but preventable adverse event. The global prevalence ranges from 9% to 53% while three million people develop HAPUs in the United States and 60,000 people die from associated complications. HAPU prevalence is reported as high as 42% in ICUs (ICU) costing on average $48,000 to clinically manage.

Objective:

The purpose of this systematic review was to evaluate the effectiveness of multi-component interventions (care bundles), incorporating the Braden scale for assessment, in reducing the prevalence of HAPUs in older adults hospitalized in ICUs.

Methods:

This was a systematic review of the literature using the Cochrane method. A systematic search was performed in six databases (CINAHL, Cochrane Library, Google Scholar, JBI Evidence-Based Practice Database, PubMed, and ProQuest) from January 2012 until December 2018. Bias was assessed with the Critical Appraisal Skills Programme Checklist, and the quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence.

Results:

The search identified 453 studies for evaluation; 9 studies were reviewed. From the analysis, pressure ulcer prevention programs incorporated three strategies: 1) Evidence-based care bundles with risk assessments upon admission to the ICU; 2) Unit-based skincare expertise; and 3) Staff education with auditing feedback. Common clinical management processes included in the care bundles were frequent risk reassessments, daily skin inspections, moisture removal treatments, nutritional and hydration support, offloading pressure techniques, and protective surface protocols. The Braden scale was an effective risk assessment for the ICU. Through early risk identification and preventative strategies, HAPU programs resulted in prevalence reduction, less severe ulcers, and reduced care costs.

Conclusion:

Older adults hospitalized in the ICU are most vulnerable to developing HAPUs. Early and accurate identification of risk factors for pressure is essential for prevention. Care bundles with three to five evidence-based interventions, and risk assessment with the Braden scale, were effective in preventing HAPUs in older adults hospitalized in intensive care settings. Higher quality evidence is essential to better understanding the impact of HAPU prevention programs using care bundles with risk assessments on patient outcomes and financial results.

The retention effect of staff education programme: Sustaining a decrease in hospital-acquired pressure ulcers via culture of care integration

Hospital‐acquired pressure ulcers (HAPUs) negatively affect patients during hospitalisation, putting patients at risk for further complications. HAPUs are one of the hospital quality key performance indicators (KPIs) that necessitate quality initiatives and/or programmes to minimise its occurrence and consequences. When quality initiatives are put into place and proven effective, the next important focus is sustainability of the effects. The original Saudi Arabian study based on data collected from 50 441 patients, showed that implementation of the pressure ulcer prevention programme (PUPP) was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The aim of this follow‐up check of the original study was to assess if the PUPP's effectiveness success was retained. Also, to try and determine why the implemented quality improvement programme to prevent HAPUs was so successfully retained. Designed and conducted as a systemic review, it tracked the outcomes of pressure ulcer rates during and post PUPP implementation that mostly focused on evidence‐based staff education, concentrating on years 2016 to 2018. Statistically significant reductions were captured by data that have been presented through Pearson Chi squares. HAPU decline was notable between year 2017 and 2018. This was followed by a further reduction in year 2018. The results determine retention effect sustainability of the initial positive results achieved. By doing so, the study was further able to establish that the PUPP had been integrated into the hospital system's care culture as evidenced by the reduction of HAPUs despite a large inpatient growth. Consideration of what contributing factors led to this successful integration of new knowledge into the care culture are also examined. KPIs can be used as indicators to help reinforce staff education. Culture of care (support of values and interventions taught during the PUPP) offer hope that these may be duplicated in future improvement projects. The supportive nature of a given culture of care may in fact be just as important as the practical education provided to staff members.

Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol

INTRODUCTION

Pressure ulcers are serious and potentially life-threatening problems across all age groups and across all medical specialties and care settings. The hospitalised elderly population is the most common group to develop pressure ulcers. This study aims to systematically review studies implementing pressure ulcer prevention strategies recommended in the Pressure Ulcer Prevention Practice Guidelines for the prevention of pressure ulcers among hospitalised elderly patients globally.

METHODS AND ANALYSIS

A systematic review of all studies that have assessed the use of pressure ulcer prevention strategies in hospital settings among hospitalised elderly patients shall be conducted. A comprehensive search of all published articles in Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science will be done using terms such as pressure ulcers, prevention strategies, elderly patients and hospital. Studies will be screened for eligibility through title, abstract and full text by two independent reviewers. Study quality and risk of bias will be assessed using the Joanna Briggs Institute for Meta-Analysis of Statistics Assessment and Review Instrument. If sufficient data are available, a meta-analysis will be conducted to synthesise the effect size reported as OR with 95% CIs using both fixed and random effect models. I² statistics and visual inspection of the forest plots will be used to assess heterogeneity and identify the potential sources of heterogeneity. Publication bias will be assessed by visual inspections of funnel plots and Egger's test.

ETHICS AND DISSEMINATION

No formal ethical approval or consent is required as no primary data will be collected. We aim to publish the research findings in a peer-reviewed scientific journal to promote knowledge transfer, as well as in conferences, seminars, congresses or symposia in a traditional manner.

PROSPERO REGISTRATION NUMBER

CRD42019129088.

Hospital-acquired pressure ulcer incident rates among hospitals that implement an education program for staff, patients, and family caregivers inclusive of an after discharge follow-up program in Saudi Arabia

A tertiary public hospital in Saudi Arabia set out in 2015 to establish a team focused on reducing hospital-acquired pressure ulcers (HAPUs). The pressure ulcer prevention program (PUPP) had a multifaceted approach and data were collected for a period of 5 years. The results showed a definite reduction in the incidences of HAPUs. Many such programs show similar positive results and echo many of the same considerations of risk, prevention strategies, and the need for early intervention. However, none of the other studies either replicate the hospital's PUPP nor the extent of the positive and lasting effect of the program. Eager to determine the contributing factor(s) in order that the project success could be continued and possibly replicated in other quality improvement projects, it was decided that an examination and comparison of other similar programs and their results would be necessary in order to uncover the answer. It was determined that the in-person in-home discharge follow-up portion of the program most likely had the largest effect on the outcomes. Outcomes that were supported by the pre-work completed during the hospital portion of the PUPP towards reducing HAPUs and readmissions.

Pressure ulcers: the core, care and cure approach

Pressure ulcer/injury remains a significant health problem in the community, requiring comprehensive care. Nurses are involved in the management and prevention of pressure injury. However, to date, studies focusing on applying nursing theory to pressure ulcer care have been limited. In the present study, the three dimensions of Lydia Hall's 1964 theory-core, care and cure-are extensively discussed and linked with the practice of pressure injury management. It is hoped that this review will help community nurses understand the application of this nursing theory to the prevention and management of pressure injury.

The effectiveness of pressure ulcer prevention programme: A comparative study

Hospital-acquired pressure ulcers (HAPUs) affect patients during hospitalisation, putting patients at risk for further complications. HAPU is one of the hospital quality indicators that require quality initiatives or programmes to minimise its occurrence and consequences. The aim of this study was to assess the effectiveness of a developed quality improvement programme in preventing HAPUs. This is a retrospective comparative study, which tracked the outcomes of pressure ulcer prevention programme (PUPP) for 5 years from 2014 to 2018. Data from 50 441 patients were collected from different units in a tertiary hospital in the eastern region of Saudi Arabia. The programme focused on building a wound care team; providing education to hospital staff, patients, and their families; and continuous data monitoring, in addition to follow-up visits after discharge. Implementation of the programme was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The PUPP was effective in reducing the percentage of pressure ulcer cases. The programme can be extended and implemented in other hospitals.

Noncontact In-Bed Measurements of Physiological and Behavioral Signals Using an Integrated Fabric-Sheet Sensing Scheme

Home monitoring requires measuring the physiological and behavioral signals without impairing a subject's everyday life. This paper presents an integrated and noncontact approach for obtaining simultaneous physiological and behavioral signals of recumbent humans in beds using a home-monitoring application. In the proposed approach, a fabric-sheet unified sensing electrode (FUSE) obtains physiological signals by recording the electrocardiogram (ECG), chest and abdominal respiratory movements (RMs), and ballistocardiogram (BCG). The FUSE also detects the behavioral signals of body proximity (BPx) and lateral/supine lying postures. A prototype system with FUSE was validated in a short-term experiment and 6-h overnight measurements on two different groups composed of seven lying subjects. The results confirmed that the approach senses each signal independently and records the ECG, RMs, BCG, and BPx signals simultaneously. The mean sensitivities of the R and T waves of the ECG during sleep were 86.1% and 88.0%, respectively, whereas those of the chest and abdominal RMs were 90.7% and 90.1%, respectively. Although our prototype system has room for improvement, the results suggest that our approach enables the unconstrained, nocturnal monitoring of the physiological and behavioral signals in recumbent humans. The at-home monitoring of the physiological and behavioral signals is expected to contribute to cost-effective personalized healthcare in the future. This noncontact and easy-to-install system for in-bed measurements can facilitate a new era of home monitoring.

The Compatibility of Chlorhexidine and a Skin Care Product Line: A Real-World Analysis of Hospital-Acquired Infection Rates

Chlorhexidine gluconate (CHG) use helps reduce hospital-acquired infections (HAIs). Chlorhexidine gluconate effectiveness can be reduced by use of skin care products. Although laboratory work can be performed to prove compatibility, such work has limitations. The purpose of this study was to compare HAI rates when CHG antiseptic wipes were used in conjunction with a silicone- and micronutrient-based skin care product line (SMSP) and when CHG wipes were used without the SMSP. Using commercial distribution data, 17 hospitals that purchased both CHG wipes and SMSP were identified. Hospital-acquired infection rates from this group were compared with HAI rates from 18 hospitals that used CHG wipes, but not SMSP. Hospital-acquired infection information was obtained from the Leapfrog Group (www.hospitalsafetyscore.org/). Four infection rates were compared: (1) infection in the blood during an intensive care unit stay, (2) infection in the urinary tract during an intensive care unit stay, (3) surgical site infection after colon surgery, and (4) average infection rate from 1 to 3. There was no significant difference between the infection rates of the two groups (Ps ranged from .285 to .983). There was also no statistically significant association between hospital grade and product use (P = .194). When considering publicly available data on HAI, there was no measurable difference in HAI rates between facilities that use CHG wipes with or without an SMSP. The SMSP does not impact the efficacy of CHG wipes.

Economic Evaluations of Strategies to Prevent Hospital-Acquired Pressure Injuries

GENERAL PURPOSE

To provide information from a review of literature about economic evaluations of preventive strategies for pressure injuries (PIs).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Identify the purpose and methods used for this study.2. Compare costs and effectiveness related to preventative strategies for PIs.

ABSTRACT

BACKGROUND: Pressure injuries (PIs) are a common and resource-intensive challenge for acute care hospitals worldwide. While a number of preventive strategies have the potential to reduce the cost of hospital-acquired PIs, it is unclear what approach is the most effective.

OBJECTIVE

The authors performed a narrative review of the literature on economic evaluations of preventive strategies to survey current findings and identify important factors in economic assessments.

DATA SOURCES

Ovid, MEDLINE, NHS Economic Evaluation Databases, and the Cochrane Database of Systematic ReviewsSELECTION CRITERIA: Potentially relevant original research articles and systematic reviews were considered.

DATA EXTRACTION

Selection criteria included articles that were written in English, provided data on cost or economic evaluations of preventive strategies of PIs in acute care, and published between January 2004 and September 2015. Data were abstracted from the articles using a standardized approach to evaluate how the items on the Consolidated Health Economic Evaluation Reporting Standards checklist were addressed.

DATA SYNTHESIS

The searches identified 192 references. Thirty-three original articles were chosen for full-text reviews. Nineteen of these articles provided clear descriptions of interventions, study methods, and outcomes considered.

CONCLUSIONS

Limitations in the available literature prevent firm conclusions from being reached about the relative economic merits of the various approaches to the prevention of PIs. The authors' review revealed a need for additional high-quality studies that adhere to commonly used standards of both currently utilized and emerging ways to prevent hospital-acquired PIs.